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Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to, claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative Policy Manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology Guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan medical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

In addition, the Plan may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., medical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in a payment policy is payable by the Plan.

If you have any questions regarding these policies, please contact Provider Services.

Last Updated: 03/29/2024